CRPC Optimising Management Practical Guide for Clinicians

Dear All,

Advances in our understanding of P Ca are occurring at a rapid pace that many find it difficult to keep pace with those. Innumerable Guidelines are available but many do not fulfill the needed information.

Neil Shore along with a group of Urological Oncologists and Medical Oncologists has attempted to provide a practical Guide for Clinicians for the current concepts to be considered for CRPC. They emphasize that this should not be for replacing existing Guidelines but could be used for improving our overall knowledge so that proper evaluations and Treatments could be offered, which for what. (PDF available)

This is a must read article which will benefit all dealing with CRPC

I am confident that there will be no response for such must read articles but if one understands the intricacies, and then the purpose is served.




  • Venugopal P
    Venugopal P
    26 Aug 2020 10:35:15 AM

    Dear All,

    I am thankful to Makarand for expressing his views on the article by Neal Shore et al the link for the same has been provided


    Thanks for asking me to review the paper on the Prostate

    My Comments:

    This is a good attempt at looking at various guidelines on mCaP and giving the readers their perspective which may have a practical value. There have been many groups  in urology /urologic oncology /oncology  across the globe  the who actually look at various aspects of international guidelines and then come out with  their 'interpretations and suggestions '  based on their own experiences.  For example we have AUA guidelines , EAU guidelines, NCCN guidelines , NICE guidelines , ASCO guidelines . Which one should we follow? What about the contradictions in a few areas?  On top of that we at BJUI came with Guidelines of the guidelines! 

     I think what matters most, is one has to see how these guidelines can be 'adapted ' in our day to day practice. I can tell you from my own experience: I was involved (still active in that group) in Asia Pacific Advanced Prostate Cancer Group APAPCC, we had a consensus conference twice and what we discussed was the 'real life scenario' and how one can adapt these guidelines in the real life practice. We published our results of APAPCC in BJUI couple of years ago. We found that exercise, though vigours and time consuming, extremely useful to our part of the world. I suggest all of you go through that.

    Management of patients with advanced prostate cancer in the Asia Pacific region: ‘real‐world’ consideration of results from the Advanced Prostate Cancer Consensus Conference (APCCC) 2017

    Declan G Murphy, Makarand Kochikar et al, 2019, BJUI, 123 (1): 22 (provided by me) (PDF available)

    So what do we take away from this paper by Neil Shore et al? To my mind, it is almost synonymous with NCCN guidelines. The authors have almost universal agreement on use of biomarkers, sequencing the treatment, bone targeted therapy and the new generation of imaging.

    We do not use Radium -233, Sipuleucel T and Apalutamide in our part of the world, so the information on this probably may not help us. But the bottom line is, encourage biomarkers, use the right sequence for newly diagnosed mCaP and use the APIs like horses for the courses.

    With Regards,


  • Ravindra Sabnis
    Ravindra Sabnis
    11 Sep 2020 09:05:52 AM

    Ca prostate is where intense research os going on, simply because it affects americans more, so they are trying to find new things. It is now suggested by almost every guidelines that only hormonal treatment in Metastatic Ca prostate is vanishing. May be some time later, even low burden mets- articles will suggest benefit. 

    Many trials have helped the man kind to have longer & better survival. But many trials have done dis-service to mankind by making simple things most expensive with marginal benefit. Many trials results are statistically significant but clinically irrelevant. Survival benefit of 1 month vs 2 months is statisucally very significant as you have doubled the survival but in reality - how does it matter when it is weighed against huge expense. So every trial as Makarand has pointed out - needs to be evaluated according what fits in our pts. 

  • Venugopal P
    Venugopal P
    11 Sep 2020 11:16:21 AM

    Dear All,

    I fully concur with Ravi when he has mentioned ‘Many trials have helped the man kind to have longer & better survival. But many trials have done disservice to mankind by making simple things most expensive with marginal benefit’. Survival for a few months is meaningless to my mind at the cost involved to achieve it. Most studies available should be looked at from Indian Perspective and not ape what the West is proposing. It should be understood that most of us in India are financially strapped and majority are not insured to take up these costly treatments. There is no doubt that we have to understand and learn all that are available in form of treatment options but should also understand how to ‘cut the sleeves from the material available’. Though pricing ultimately could be different (ultimately) for India as have been noticed with Abiraterone and now Enzalutamide (the same may follow for other newer molecules as well), at present they appear so costly that it may not fit the pockets of the majority.

    At present Cost of many of these drugs and treatments are prohibitive for an average Indian. The cost of some of these drugs and treatments are as follows:

    Apalutamide - estimated price for a 30-day supply of 120 tablets is about $10,000.

    Darolutamide costs $11,550 for a 30-day supply

    In India Olaparib is available at Rs80000/per bottle

    In India Rucaparib is available for Rs 1.3 Lakhs/bottle

    In India Atezolizumab Rs 1.6 Lakhs – Packaging size 20 mL

    Diagnosis of the prostate cancer with PSMA-PET - from Indian Rs 1,62,567 (Germany)

    Prostate Cancer Treatment with Lutetium 177-PSMA from - Indian Rs 12,77,845 (Germany)

    The latest Kid on the block is Relugolix which is am Oral ADT and Costs around $12,800 per 120 tablets.

    In India, is imperative that we provide low cost but efficient treatment. In advanced mP Ca, with longevity of life curtailed, the effort should be on maintaining the quality of life.

    Recently, many studies are mentioning the utility of Oestrogens for Advanced P Ca. It has been well established that majority of cardiovascular toxicities are associated with the first pass of the drug through liver on Oral ingestion of Oestrogens. Hence Transdermal Oestrogens are considered better alternative. Frank Hohenfelner, one of the past President of AUA has mentioned that he had a much better quality of life when he was on Oestrogens and he had somewhat a miserable time when he was being treated with other drugs. The dreaded Osteoporosis associated with the usual ADTs is not seen with Oestrogens. Why is that Oestrogens are not making a comeback. It is mainly due to the Pharma’s who deliberately is keeping Oestrogens away as these are available at minimal cost and the profit margin selling them is low. But there possibilities for this to change as Drugs using Oestrogen Receptors are on the anvil and will be costly and then the Pharma’s will start pushing them as drugs from Manna.

    I request all practicing in India to consider the costs involved in the proposed treatments and if there are suitable, well meaning alternatives, they be employed.

    With warm regards,



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